PREVIOUS NOTE
NOTA PRÉVIA
Study on Liquid-Based Cytology (SurePath) of the
Association between Candida Species
in Women with Bacterial Vaginosis
José Eleutério Jr1, Mauro Romero L Passos2, Paulo César Giraldo3,
Iara M Linhares4, Newton Sérgio Carvalho5
Although the Pap smear does not have as its purpose the microbiological diagnosis, the Brazilian Nomenclature for Cytological Reports(1) and the Bethesda System suggest that the method
can point to the presence of morphotypes of bacteria, fungi and
parasites(2).
Authors have studied the Papanicolaou method for identifying
pathogens with different sensitivities, specifically in the diagnosis of bacterial vaginosis, candidiasis and trichomoniasis ranging
from 30 to 90%(3,4). The subjectivity of the method and not using
of immersion objective of the microscope, and the habit of using Papanicolaou for screening but not for microbiological diagnosis,
explain differences in sensitivity. Who works with Papanicolaou
is cytopathologist, not microbiologist, so with a different focus.
With the introduction of methods of liquid based cytology appears to have been significant improvements in detection rates of
fungal but not bacterial vaginosis and Trichomonas(5).
The identification of association between microorganisms has
been observed with frequently between vaginosis and Trichomonas and bacterial vaginosis and Actnomyces(6). Few have been
concerned by the possibility of observing the association between
presence of Garderella vaginalis and Candida, which is possible(7).
Although the difference in pH could be a factor impeding the
coexistence of candidiasis and bacterial vaginosis, no one knows
for sure how often this association occurs.
The objective of this study was to identify the frequency of
Candida sp. and bacterial vaginosis and what factors might be
associated with a greater chance of finding in cytology in liquid
medium.
It was conducted a cross-sectional pilot study in 272 women
diagnosed with bacterial vaginosis by finding over 20% of “clue
cells” in Papanicolaou smear(8) processed by liquid-based method
(SurePath). Data from medical records of patients were studied
and the smears were evaluated by experienced cytopathologist
1 Professor Adjunto – Faculdade de Medicina – Universidade Federal do
Ceará.
2 Professor Associado, Chefe do Setor de DST da Universidade Federal
Fluminense.
3 Professor Titular de Ginecologia – Faculdade de Ciências Médicas –
Universidade Estadual de Campinas.
4 Professora Livre-docente – Faculdade de Medicina – Universidade de
São Paulo.
5 Professor Titular de Ginecologia– Faculdade de Medicina – Universidade
Federal do Paraná.
in immersion lens to identify morphotypes and identification of
inflammatory infiltrate. It was searched Trichomonas vaginalis,
Candida sp., Mobiluncus sp., Actinomyces sp., cytopathy suggestive of herpes simplex virus and Chlamydia trachomatis. Cytopathy HPV induced cases were excluded because they were considered
intraepithelial lesion. Inflammatory infiltrate was considered as
the presence of more than five polymorphonuclear leukocytes
per epithelial cell in field immersion (1.000x). To study the association of morphotypes was recorded the frequency of each
pathogen, Fisher exact test and odds ratio were evaluated for a
confidence interval of 95%.
The age of the women studied ranged from 18 to 66 years
(mean = 35.6 ± 10.9) with a number of pregnancies referred from
0 to 11 (mean = 1 ± 2). Only 44 (14.2%) said the use contraception, the most common being oral contraception. Among the 98
patients studied (36%) reported at least one symptom of which
the most common was only discharge in 41 cases (42%). In the
study of smear was observed that 119 cases (44%) had inflammatory infiltrate different than normally expected for bacterial vaginosis. Among the surveyed morphotypes were found Mobiluncus
sp in 43 cases (15.8%), Candida sp. in 18 cases (6.6%) (Table 1),
Trichomonas vaginalis in one case (0.4%), Actnomyces sp. in one
case (0.4%) and suggestive of Chlamydia trachomatis in one case
(0.4%). Using the inflammatory infiltrate as predictive of mixed
infection was observed that there appears to be a relationship between the absence of leukocytes and the presence of Mobiluncus
sp. (odds ratio = 0.2409 [0.1071 – 0.5420]), whereas in the presence of leukocytes there is greater chance of Candida sp. (odds
ratio = 175.1667 [23.0738 – 1,329.7932]) (Table 2).
These findings demonstrate an important trend in frequency
of mixed infection of anaerobic bacterial vaginosis detected by
the presence of Gardnerella morphotype and candidiasis, particularly when there is inflammatory infiltrate in the vaginal smear.
Other researchers in this retrospective study identified association in 29.7% of the women(6). In recent reports the diagnosis of
this association was observed in 22.1% of 471 cases studied using
Pap test and Nugent score on Gram and Gram stain for diagnosis
of bacterial vaginosis(7), and in 11.7% of 668 women by culture
and BD Affirm ® VPIIITM(9). The star point of the diagnosis and
diversity of methods may justify the difference between the frequencies identified as well as the actual number of cases. Anyway
seems to get the alert for the microscopist that the presence of
inflammatory infiltrates where there is Gardnerella morphotype,
one must search in immersion lens, Candida morphotype.
DST - J bras Doenças Sex Transm 2012;24(2):124-125 - ISSN: 0103-4065 - ISSN on-line: 2177-8264
DOI: 10.5533/DST-2177-8264-201224212
Study on Liquid-Based Cytology (SurePath) of the Association between Candida Species in Women with Bacterial Vaginosis
Table 1 – Comparison of the frequency of association of bacterial vaginosis and candidiasis in cytology
Método diagnóstico
Frequência da associação de vaginose
bacteriana e candidíase
Fresh exam and culture
7.9% (16/202)
Pap test
22.1% (104/471)
Saleh et al. (2012)(9)
Gram, culture and BD Affirm VPIIITM®
11.7% (31/264)
Results of this study
Liquid-based cytology (SurePath BD®)
6.7% (18/272)
Fonte
Di Bartolomeo et al. (2002)(6)
Wei et al. (2012)(7)
Table 2 – Study of the chance of association between bacterial vaginosis with Mobiluncus and Candida sp. depending on the
presence of inflammatory infiltrates in cytological smear
Mobiluncus absent
Mobiluncus present
p
OR
With inflammatory infiltrate
111
8
0.0002
0.2409 (0.1071 – 0.5420)
No inflammatory infiltrate
117
35
Candida negative
Candida positive
p
OR
With inflammatory infiltrate
102
17
< 0.0001
175.1667 (23.0738 – 1,329.7932)
No inflammatory infiltrate
151
1
Fisher’s exact test with a confidence interval of 95%.
Thus it is evident the need for a large multicenter prospective
study to estimate the actual frequency of the association between
bacterial vaginosis and vaginal candidiasis basing new diagnostic
and therapeutic perspectives.
Conflict of interest
No conflict of interest to declare.
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Address to correspondence:
José Eleutério Junior
Departamento de Saúde Materno-infantil – Faculdade de
Medicina (UFC)
Rua Prof. Costa Mendes, 1.608 – 2o andar
CEP: 60430-140 – Rodolfo Teófilo, Fortaleza – Brasil
Fone: (5585) 3366-8041 – Fax: (5585) 3366-8040
E-mail: [email protected]
Received in: 22.11.2012
Approved on: 05.12.2012
DST - J bras Doenças Sex Transm 2012;24(2):124-125